Top 10 Reasons Adjusters Use to Deny Your Workers’ Comp Claim

1.   No accident arising out of and in the course of employment – Adjuster alleges that you did not suffer an accidental injury while at work.  Sometimes this means there was no accident and sometimes it means you may have a condition that is not work-injury related.
2.   Intoxication or drugs – Adjuster claims that although there was an accident, they don’t have to pay you because you ingested alcohol or drugs which is what caused the accident.
3.   Horseplay or willful misconduct – Adjuster claims although there was an accident, once again they don’t have to pay you. In the case of horseplay, you were the instigator and not an innocent bystander. And in the case of willful misconduct, for example, the adjuster claims you obstinately refused to wear a safety harness, and not just forgot, which resulted in the accident.
4.   Scheduled lunch or rest break – Adjuster claims that you were injured when you were on a regularly scheduled lunch or rest break and had freedom of action to do what you wanted during your break including leave the premises.
5.   Deviation or detour – Adjuster claims that you were injured when you deviated or took a detour from your employment duties to engage in a personal mission.
6.   Idiopathic condition – Adjuster claims that you were injured by a condition that is personal to you. For example, you passed out due to a seizure and fell and hurt your back on the floor.  Because the seizures are personal to you, the fall is not covered.  However, the back injury would be covered if your back struck a table, desk or piece of machinery as you fell.
7.   Independent contractor – Adjuster denies your claim because you are not an employee.  In order to be covered by workers’ comp, there must be an employee-employer relationship.  Many employers try to avoid paying for workers’ comp insurance by alleging that their employees are independent contractors when they are actually employees.  Does the company have “the right” to control what you do?  Does the company have the right to tell you what time to be at work, what to wear, what to do, when to do it, and how to do it? The determining factor is whether the company has the right to exercise control over you, even if the company doesn’t actually use it.
8.   Statute of limitations bar or no notice defense – Adjuster denies your claim because the statute of limitations has run. There’s a one year statute of limitations that runs from the date of accident. If the insurer paid medical benefits, the statute of limitations is extended from the last furnished remedial care.  This is tricky because not all medical treatment is considered remedial. Best practice is to file a WC-14 Notice of Claim within one year of your date of accident to toll the statute of limitations or talk to an attorney to determine when your statute of limitations runs. If you were paid temporary total or temporary partial disability benefits, there’s another statute of limitations to consider and that’s the two year statute if you become disabled within two years of last payment of temporary total or temporary partial disability benefits. To toll the two-year statute you will need to file a WC-14 Hearing Request seeking additional temporary total and/or temporary partial disability within last payment of such.
Adjuster denies your claim because you failed to notify your employer of your accident within 30 days. There are some exceptions for failure to give notice: 1) you were physically or mentally incapable, 2) you were prevented by fraud or deceit, 3) your employer or your immediate supervisor or foreman had knowledge of the accident, or 4) where you have a reasonable excuse for not giving such notice “to the satisfaction of the State Board of Workers’ Comp” and you reasonably prove “to the satisfaction of State Board of Workers’ Comp” that the employer had not been prejudiced thereby.
9.  No disability or “medical only” – Adjuster denies in part by disputing entitlement to lost wage benefits. Your claim is covered as a “medical only” claim but income benefits are not being paid either on the grounds that your authorized doctor released you to regular duty work or to light duty and your employer offered you suitable light duty work from the beginning.
10.  No insurance coverage – An employer who has fewer than 3 employees regularly in service in the same business within the State of Georgia is not subject to the Workers’ Compensation Act.  In that scenario, your employer is not required to carry workers’ comp insurance. You will need to talk to an attorney to determine whether your company should have workers’ comp.  Keep in mind that your boss has the right to exempt himself and some other employees from coverage.

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